History

The history may be sufficient to make presumptive diagnosis of a disc disorder, or it may guide the physician's usage of ancillary testing and consultations to further differentiate both the specific type of disc disease and potential other etiologies of the patient's back pain.

Patients with disc disease usually are not able to give a precise time that the problem began because it usually is preceded by multiple episodes of less severe low back pain.

Asking the patient the location of the pain is important. Pain that is localized to the lower back and gluteal area is often associated with disc disease. Pain associated with nerve root involvement commonly radiates down the leg, particularly below the level of the knee.

Ask the patient about any unusual recent activity, especially if it involved the patient remaining in a flexed or rotated position. Find out if the patient experienced any recent trauma. Pain with flexion, rotation, or prolonged sitting or standing, as well as sharp (rather than dull) pain, is suggestive of disc disease.

The onset of pain may begin suddenly^[5]or gradually after injury. Typically, the pain is located bilaterally at the posterior belt line. The pain pattern usually is referred rather than radicular. Back motion, which includes sitting, standing, lifting, bending, and twisting, usually aggravates the pain; it often is relieved with rest and a recumbent position.

Physical

Nerve roots exit the spine below the intervertebral disks; thus, herniation of a disk involves the nerve root below it.

Observe the patient for abnormal gait, which is suggestive of a loss of the normal rhythm. Have ambulatory patients walk on their toes to test the function of S1.

Observe the patient for abnormal posture, which is suggestive of splinting or guarding from pain.

Test the patient's ability to dorsiflex the foot while sitting to test the L5 nerve root. Test for sensory loss that corresponds to a dermatomal area.

Palpation of the lumbar spine and lower back is not helpful in the diagnosis of disc disease, but it should be done to rule out other causes of low back pain.

A positive straight leg raising test is indicative of nerve root involvement. This test is performed while the patient is lying supine with one leg either straight or flexed at the knee, with the sole of the foot flat on the stretcher. The other leg is kept straight and lifted by the examiner. If pain occurs when the leg is lifted between 30-70 degrees from horizontal and travels down the leg until below the knee, the test is positive.

Nerve root stretch test results are often negative.

Patients may exhibit decreased lumbar range of motion (ROM).

The usual motor, sensory, and reflex examinations (including perianal sensation and anal sphincter tone when appropriate) should be performed.

A careful abdominal and vascular examination is mandatory.

Differential Diagnoses

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Author

Jere F Baldwin, MD Medical Director, Department of Emergency Medicine, Mercy Hospital Port Huron

Jere F Baldwin, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Emergency Physicians, American Medical Association, Michigan State Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey Horwitz, DO Director, Assistant Clinical Professor, Department of Emergency Medicine, North Shore University Hospital at Forest Hills

Jeffrey Horwitz, DO is a member of the following medical societies: Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Mark S Slabinski, MD, FACEP, FAAEM Vice President, USACS Central

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Ohio State Medical Association

Disclosure: Nothing to disclose.

Sections Lumbar (Intervertebral) Disc Disorder Management in the ED
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
References

Lumbar (Intervertebral) Disc Disorder Management in the ED Clinical Presentation

History

Physical

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